The health insurance represents a pillar of the French system of social security (apart from retirement precautions, workers’ compensation and family allowance insurance). Therefore everyone (with domicile in France) receives protection through insurance regardless of age, income, gender and state of health (principle of solidarity). Approx. 80% of all French people are insured with the general health insurance, the so-called Régime général d`assurance maladie. The insurance covers financial risks caused by illness, maternity, disability and death. Moreover, the insurance offers financial protection in case of industrial accidents and occupational diseases.

There are also special health insurances apart from the general health insurance, for
· self-employed persons, artists and traders (3.1%)
· farmers (4.2%)
· some occupational groups like sailors, miners or railwaymen

Further 2% of the population (students and persons, who do not belong to the area of responsibility of a professional insurance system) are compulsorily insured with the universal health insurance within the general health insurance, Couverture maladie universelle (CMU; please also read the chapter “additional insurance” on this matter). The CMU came into force on January 1, 2000 in order to introduce a compulsory health insurance not connected with a certain occupation. In this way the ultimate 150.000 – 200.000 persons are included in the governmental compulsory insurance.

The insured party pays partly in advance in case of service claims, i.e. pays the operator and submits the invoice at the insurance. The health insurance also pays the part of the costs directly, which are covered by them. In case of many services the insurance only covers a part of the cost. Approx. 75% of medical costs and around 70% of drug costs will be covered. 100% of the costs will be covered in case of the needy (e.g. annual income less than 6744.- € or for mothers during their definite motherhood or in case of chronic ill people).

Due to the fact that it is a governmental health system, the state covers the according services. These are:
· Control of financial institutions
· Education of qualified health employees
· Establishment of the performance requirement for qualified health employees
· Control of quality standards
· Provides information regarding general topics of health, like prevention, vaccination or the fight against different diseases and cares about according matters
· Regulation of the service supply
· Supervision of regional hospital agencies; exists since 1996 and is responsible for regional health politics in the sector of stationary care
Furthermore, the state provides some specialist units. Examples are:
· Institute for health monitoring

· French agency for security regarding health services and the product sector
· Institute for blood donation
· Agency for food security

History
In 1945 the Sécurité Sociale was founded with equal representatives of employers and employees. The state has been playing a fundamental role from the beginning, which has become even stronger over the years. In 1995 a reform took place. From this time the parliament is passing the annual budget for the health insurance. The money for the health insurance comes from contributions, which are calculated from the income (not only workers’ salary) of the individual (contribution proportionelle sur tous les revenus).
The health system has been in crisis since 1976 and is permanently subject to reforms. Since then more than 20 reform plans took place, but they didn’t have the desired outcome. The contents of the reform plans were:
· Increase of contributions or taxes
· More extra payments for drugs
· Establishment of a health insurance clause and limitation of the cost assumption regarding this health insurance clause
· Increase of the percentage share concerning the daily hospital rate

In 1991 the General Social Contribution (CSG) was introduced. Please read the chapter “Financing”.

In 1996 a contribution for the repayment of the social indebtedness (remboursement de la dette sociale) was introduced (0.5% of the total income). This contribution has been introduced with an expectation for the next 13 years with the aim to pay off the high debts of the governmental health system. The government of Jospin extended this contribution to 18 years. At the moment a further extension is being discussed. (Homepage - Vergleich private Krankenversicherung)

Prevention always used to play a minor role in the French health system, but this should be changed in future. The current aim is the promotion of public health and the reduction of wrong behaviour (Jean-Francois Mattei is in overall charge). In January 03 the price of tobacco has been increased heavily (15%).

Financing

The biggest part of the money for health services comes partially from social contributions on salary and income and partially from the General Social Contribution (CSG).
The contributions on salary and income are not divided into equal shares on employer and employee, like in Germany. They also refer to the total gross salary, without income limit. The employers’ share is 12.8%, the employees’ share is 0.75%. As this low employees’ share was not sufficient, the earlier mentioned CSG was introduced in 1991. It is 7.5%, calculated from 95% of the gross salary. The CSG is inclusive all income, as well as the income of capital and property.

The problem regarding this financial system is that the revenue of the general health insurance is dependend on the economy. In 2003 a economical growth rate of 2.5% was originally expected. However, the growth rate turned out to be a lot less, which also resulted in considerable minor proceeds. The bad budget situation also had consequences on the deficit of the health insurance. Since a reform in 1995 through Juppé, this deficit became less thanks to a better state of economy (between 0.2 and 0.5 billion Euros).

Services:

There are non-cash benefits and money-related services. Moreover an insurance for industrial accidents, disability and death are being offered.

The insurance cover applies to various costs for
· care through general practioners as well as specialists
· care services
· artificial limbs
· pharmaceutical products
· medical aid
· analysis and laboratory eximination
· stay and treatment in care facilities, rehabilitation clinics and surgical stations
· part of the transportation costs
· medical and pharmaceutical care in case of maternity; also aid care and hospital stay
· medical observation of newly born children
Care services, which are required due to the state of health, will be covered for people in need of care. In this case we talk about special supplements or efficiency bonuses.
In case of inability to work, cash bonuses exist, after an illness or due to an accident. Moreover, women receive bonuses during their maternity leave.
The insured parties have unlimited access to health services.

The costs for health services are not completely covered by the health insurance, which resulted in the fact that many French people took out additional insurances.

There are certain established rates for non-cash benefits (The costs can go beyond fixed rates; especially in case of visual aids, dentures and hearing aids, the rates are clearly exceeded; the patient has to pay for the difference). This rate will be covered minus a percetage excess. This percetage excess can vary. It is 30 - 40% for care through established doctors and auxilary staff, 35 – 65% for medicine, 40% for analysis and/or laboratory examinations, 0 – 20% for hospital treatments and 35% for medical aid. It is possible to receive a partial or complete service coverage for certain services and for certain groups of service recipients.

The patient can choose his doctor freely, also the specialist. For the consultation of a specialist it is therefore not necessary to get a referral through the general practioner. The patient pays the doctor directly. There is an opportunity for the patient to pay only the percentage excess.

Additional insurance:

In general 87% of the population is additionally insured, either through a company on a reciprocal agreement, through insurance companies or through pension funds. The majority is insured through one of the 6500 companies on a reciprocal agreement. Those cover alltogether more than 7% of the total expenses of the health sector.

In 1999 the law of the introduction of the general additional insurance - CMU (Couverture Maldie Universelle) was introduced. It was created because of the fact that 18% of the French didn’t have an additional insurance. The compulsory health insurance covers in fact 75.4% of the most common expenses and 91.3% of the costs of a hospital stay. However, only 64.2% of out-patient treatments and 58.5% of medical goods like medicine will be covered. This lead to the fact that many people had to live without medical care out of financial reasons.

Two years after its’ introduction, 4650000 people are additionally insured with the CMU, 85% through the social health insurance Caisse de Sécurité Sociale and 14% through traditional additional insurance companies.
However, a different distribution is desired. This distribution was achieved because the majority of people was assigned automatically to the social health insurance. The expenses per insured party through the social health insurance are approx. 1953 Euros, which means that this is 30% higher than the costs of other patients. These are still the problems to be solved.

Thoughts and measures regarding cost reduction

The expenses regarding health services are also growing too high in France. A reason for it can be the rising of the ageing population. That is why the costs are increasing by approx. 1.5% of the GDP. What are/were the measures concerning this deficit:
· First of all a strict price control. Therefore the prices for medication are fairly low on the European market.
· Stricter measures for the prevention and promotion of health
· Creation of a company for health services with extended competences (further nationalisation)
· Transfer of the administration of hospitals to a regional level
· Further development of the out-patient surgery to lower the costs of stationary treatments
· Creation of a net to better coordinate different suppliers of health services
Setting up of rates for pathological treatments for hospitals
Finally generic drugs should be mentioned. It is a medicine, made from a tested active substance, as soon as the patent right has expired. Generic products have the same effect and the same quality as original products, sometimes even a better form of use. Since 1996 the use of generic drugs in the sector of medicine is promoted. At the moment especially medicine with non-provable medical benefits became the centre of attention. The prices of such drugs are going to decline and certain refund rates are planned to be introduced. Pharmacists are able to replace a prescriptive medicine from a doctor with a generic drug. The margin was brought into line with the products of reference. But it turns out that the share of generic drugs is relatively low.
Figures (from 2001)
France has approx. 59.196.600 inhabitants. The life expectancy is 75.9 years for men and 83.0 years for women. The infant mortality (per 1000 life-births) amounts to 1.9. There is one doctor for 302 inhabitants, one dentist for 1464 inhabitants. In 2000 public expenses for health services amounted to 9.5% of the GDP.